Heart: An American Medical Odyssey (6 page)

I am happy the doctors have given me at least a parole if not a pardon. I expect to be back at my accustomed duties, although they say I must ease my way into them and not bulldoze my way into them.

The treatment administered for Dick Cheney’s myocardial infarction was remarkably similar to that received by Eisenhower twenty-three years earlier, both focusing mostly on rest. After an uneventful eleven days
in the hospital, Cheney was advised by Dr. Davis to remain “homebound with in-house activity” for an extended period of time.

Dick Cheney’s care did differ in one important aspect from that delivered to President Eisenhower: Mr. Cheney was monitored in a coronary care unit, an innovation introduced just a few years after Eisenhower’s hospitalization and the first advance in the treatment of heart attacks that actually lowered mortality.

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In the 1920s, as electrical power was being disseminated throughout homes and businesses in the United States, it was becoming common for utility linemen to die after accidental electrical shocks. It had been known since the mid–nineteenth century that electricity could cause a chaotic and fatal arrhythmia called ventricular fibrillation, but the prompt restoration of a normal heart rhythm remained an elusive problem. Ventricular fibrillation, also a dreaded complication of acute myocardial infarction, causes cardiac output to cease and blood pressure to drop to zero, halting the delivery of oxygen to the tissues, a condition called anoxia. While some organs can tolerate anoxia for an extended period of time, the brain cannot, and after just a few minutes, irreversible brain damage occurs.

In 1933, William Kouwenhoven, an electrical engineer, and colleagues at Johns Hopkins University reported experiments, funded by the Edison Electric Institute, in which for the first time they were able to reverse ventricular fibrillation and restore a normal rhythm by applying a “countershock” of electricity to the thorax of a fibrillating dog.
The first successful defibrillation of a human patient occurred in 1947, but only after the chest of the fourteen-year-old boy was opened and electrical current was applied directly to the surface of the quivering heart. The boy made a full recovery.

In the years that followed, more patients were resuscitated from in-hospital cardiac arrest in this manner but only after enduring an emergency thoracotomy in which an incision was made along the left side of the chest, the ribs spread to expose the heart, and defibrillator paddles
placed directly against the muscle. Although a step forward, this technique was hampered by two major drawbacks. First, it required an around-the-clock in-house team of skilled surgeons to “crack” the patient’s chest, and second, and just as important, it was time-consuming, a major disadvantage when the time window for resuscitation is a very few minutes. There was thus a need for technology that could promptly detect life-threatening arrhythmias, enable defibrillation of the heart without having to open the chest, and, perhaps of paramount importance, keep the patient alive until defibrillation could be accomplished. Within several years, all three pieces would come together.

In 1956, one year after President Eisenhower’s heart attack, Dr. Paul Zoll, a Harvard cardiologist, successfully resuscitated a sixty-seven-year-old man using a new external defibrillator, for the first time obviating the need to open a patient’s chest.

One year later, Zoll developed a method to display a patient’s cardiac electrical activity on an oscilloscope equipped with an alarm capable of detecting a cardiac arrest. This revolutionary technology permitted real-time surveillance of cardiac patients for life-threatening arrhythmias.

The final piece of the resuscitation puzzle came in 1960 when researchers at Johns Hopkins University described a method of “closed-chest massage” capable of pumping blood in and out of the heart without opening the chest. William Kouwenhoven (who twenty-seven years earlier pioneered defibrillation), James Jude, and Guy Knickerbocker, in a landmark paper published in 1960 in the
Journal of the American Medical Association,
reported their simple method to squeeze the heart between the sternum and spine by compressing forcefully with the heel of a hand. Kouwenhoven and colleagues wrote:

Cardiac resuscitation after cardiac arrest or ventricular fibrillation has been limited by the need for open thoracotomy and direct cardiac massage. As a result of exhaustive animal experimentation a method of external transthoracic cardiac massage has been developed. . . . Anyone,
anywhere can now initiate cardiac resuscitative procedures. All that is needed are two hands.

The stage was set for a new way to monitor and resuscitate cardiac patients, and at the meeting of the British Thoracic Society at Harrogate in North Yorkshire, England, on July 15, 1961, Dr. Desmond Julian presented a paper in which he described the rationale for the first coronary care unit:

Many cases of cardiac arrest associated with acute myocardial ischaemia could be treated successfully if all medical, nursing, and auxiliary staff were trained in closed-chest cardiac massage and if the cardiac rhythm of patients with acute myocardial infarction were monitored by an electrocardiogram linked to an alarm system.

Years later, Julian noted that it was essentially the success of closed chest cardiac resuscitation that triggered the creation of the coronary care unit (CCU). Julian opened the first CCU in Sydney, Australia, in November 1962 and was soon followed by colleagues in Kansas City, Toronto, New York, and Miami.

Concentrated monitoring in a coronary care unit enabled physicians to rapidly recognize and reverse a variety of complications after a heart attack. Crucially, nurses were given the responsibility for the detection of ventricular fibrillation and its treatment with defibrillation. The nursing staff could quickly attend to ventricular fibrillation, often before the arrival of a physician. Continuous EKG monitoring could detect heart blockage or other slow heart rhythms, allowing treatment with a pacemaker prior to a cardiac arrest. Patients with low blood pressure or other symptoms of shock could receive medication such as norepinephrine from a staff specially trained to administer and adjust these drugs.

The net result of this new model of acute cardiac care was a substantial drop in in-hospital deaths. During the 1950s, when President
Eisenhower experienced his myocardial infarction, 30 percent of patients died during their hospitalization. In the era of the coronary care unit, the in-hospital death rate declined to 15 percent.

Eleven days after Dick Cheney was admitted to the CCU in Cheyenne Regional Hospital with an acute inferior wall myocardial infarction, he went home. The sole medication prescribed to him on discharge was Anturane (sulfinpyrazone), a drug typically used to lower uric acid levels in patients with gout, but used in his case to prevent a recurrent heart attack because of its aspirin-like inhibitory effect on platelets, the blood cells that are essential to clot formation.

Today, a patient discharged following a heart attack will be treated with a host of medications, including antiplatelet drugs like aspirin and clopidogrel (Plavix), statin medications like atorvastatin (Lipitor) or rosuvastatin (Crestor) to reduce cholesterol, beta blockers to slow the heart rate, and ACE inhibitors to prevent congestive heart failure.

Following an exercise stress test three weeks after the heart attack, during which Cheney had no chest pain or concerning EKG changes, Dr. Hiser prescribed an exercise program consisting of thirty minutes per day of walking at a target heart rate of 120 beats per minute. Even with the reassuring stress test, Hiser remained cautious and somewhat ambivalent about Cheney’s return to the campaign. In a July 10, 1978, letter to Dr. Davis, he wrote:

His plans for the campaign are now familiar to you . . . he will resume the campaign, but not actively until late July or early August. Jumping fully into the campaign will be delayed until mid-August. Even at that time he has been admonished to not excessively fatigue himself and to maintain his exercise program and to get a full eight hours sleep every night. . . . The campaign is so important to him that I am reluctant to tell him that he should drop out of it.

At the end of July, Cheney was allowed to resume limited campaigning but only after Dr. Hiser issued strict conditions, underscoring the fragility of a post-MI patient. In September 1978, with the campaign
for Congress in full swing, Dr. Hiser ordered blood tests that documented an elevated total cholesterol of 271 mg percent (the normal range 110 to 253) and a triglyceride (a type of lipid) of 334 mg percent (normal range 29 to 201). In view of these abnormal results he reminded Cheney of the importance of adhering to the restricted diet and advocated weight reduction and continued exercise. Dick Cheney didn’t need to be reminded about tobacco; he smoked his last cigarette the day he had his first myocardial infarction.

On election night, November 7, 1978, we watched the returns with friends and campaign aides at our home in Casper. We set up extra TVs in the dining room and study so we could watch all three networks and the local Casper station, KTWO. I had won the three-way primary that August with 42 percent of the vote, the smallest total I would ever receive during my congressional career. I suspected that the primary fight would be tougher, and the outcome closer, than the general election, but no successful politician takes anything for granted. Watching the returns come in and seeing that I’d been elected to the US House of Representatives with 59 percent of the vote that November night was a life-changing experience. I felt privileged to be selected by the people of Wyoming to represent them in Congress. Thirty-five years later, after holding other positions of high office, no title ever made me prouder than being known as the Gentleman from Wyoming.

The morning after the election, I called Congressman John Rhodes of Arizona, the Republican leader in the House of Representatives. Rhodes had succeeded Jerry Ford as the minority leader in the House in December 1973 when Nixon selected Ford to be his vice president, and I got to know Rhodes when I served as White House chief of staff. As the minority leader in the House, Rhodes would have a major voice in committee assignments for the newly elected Republican members of the Ninety-Sixth Congress. I asked him to consider me for a seat on the Committee on Interior and Insular Affairs. As a public lands state
where the federal government owns 50 percent of the surface and 65 percent of the mineral rights, Wyoming is affected greatly by decisions that come within the jurisdiction of the Interior Committee.

Rhodes said he thought there wouldn’t be any problem with fulfilling my request. Then he added that he wanted me to take a seat on the Committee on Standards of Official Conduct, better known as the Ethics Committee. The committee’s jurisdiction includes conducting investigations of alleged wrongdoing by members accused of violating House rules. If members are found guilty, the committee is charged with recommending appropriate sanctions to the full House up to and including expulsion.

The power invested in the Ethics Committee to sit in judgment and sanction members has led to a set of rules that are unique. The committee always has an equal number of members of both parties (six Republicans and six Democrats in 1978). Although the chair was of the party that controlled the majority in the House, no significant action could be recommended to the House without at least seven votes. The leaders are careful to appoint only members they believe will understand the significance of the responsibility and will conduct themselves in a manner that puts the interest of the House of Representatives ahead of personal or partisan interests. Freshmen are rarely selected to serve on the committee. Rhodes’s decision to appoint me indicated he had confidence in my experience and judgment to handle the assignment. I readily accepted.

A week after the election, Lynne and I took the girls to Hawaii. We spent some time on the big island of Hawaii at the home of our friend Jack Ellbogen. We also spent a few days in Honolulu with Congressman Bill Steiger and his wife, Janet. Bill, who’d been my first boss in Washington, was a rising star in the Republican Party. We enjoyed a wonderful few days of rest and relaxation before we all went to Washington to take up our places in the Ninety-Sixth Congress.

A few weeks later, I was in Washington for the orientation sessions for new members. Many of our meetings were held at the Dulles Marriott Hotel, but we also gathered for introductory meetings at the Capitol.
On December 4, 1978, I stepped out of the organization meeting of the Republican conference for a photo shoot with
U.S. News & World Report
. As I emerged onto the steps of the Cannon House Office Building, I noticed the flag over the Capitol was being lowered to half-staff. I asked one of the Capitol police officers standing nearby why they were lowering the flag, and he explained it was because a member of Congress had just died. “Who?” I asked. “Bill Steiger of Wisconsin,” came the answer. I was stunned to learn that Bill had died of a heart attack in his sleep. He had just turned forty, only two years older than I was. When I’d had a heart attack in the middle of my first campaign six months earlier, Bill had urged his donors to write a check to me in Wyoming.

Bill’s funeral was held in Oshkosh, Wisconsin, a few days later. Though I hadn’t yet been sworn in, I was granted permission to fly with the official delegation of Bill’s colleagues from the House. The service was especially poignant because Bill had been so young and because we all knew he’d had such a bright future ahead of him. His death was a tragedy for his family, for those of us who knew him, and for the nation.

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Even the death of such a close friend and mentor from a heart attack did not cause me to think much about my own mortality. I considered my heart attack as a one-off event, and I basically thought of myself as healed.

I was leading an active life physically, playing tennis and planning a ski trip for the upcoming holidays. I’d quit smoking, was watching my diet, and trying to exercise regularly. I was doing what a prudent man would, but I also was in denial to some extent. I told myself I had dealt with my heart problem by quitting smoking. I certainly didn’t think of myself as sick or even as someone suffering from coronary artery disease.